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� SAN JOAQUIN LOCAL HEALTH ]DISTRICT <br /> FOR 'O ' ICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :3 2- , ,? `7 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 9- y 7T/ <br /> (Complete In Triplicate) <br /> Application, is hereby ma. e to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the •Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1_67 �Z .S'r ,� ����v, .� HCl/' CENSUS TRACT �� `T <br /> Owner's.Name �� �� � $8 / Phone ' <br /> Address -s�4d �S� �,? t7_.J 1 Z&o l,� �U ' City 1 � <br /> Contractor's Name L z t5 C)IL, License # Phone g <br /> r -TYPE-OF-WORK.:(Check) :—NEW '�WELL / /=DEEPEN=-/ /—RECONDITIONS/-w/-;-DESTRUCT ONS_—J_-._�_.._. ....�. ... <br /> ­ PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> x <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth'..of Grout Seal ,. ., r <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /S tate Work Done P�� S /{P T �►afs L� <br /> PUMP REPAIR: /7 State Work Done <br /> ,DESTRUCTION OF WELL• Well Diameter ApproxiuiatYe'-Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE- <br /> k (DRAW PLOT PLAN ON REVERSE SIDE '• Ma <br /> f �7 FOR WPAR.74qNUSE ONLY <br /> PHASE I <br /> F APPLICATIONACCEPT DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P /FINAL INSPECTION <br /> _ INSPECTION BY •--' DATE INSPECTION BY Z . DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M C� <br />